Deb Anderson

AS A great biomedical revolution unfolds, providing relief for millions consigned to pain, misery and early death, Australian Nobel laureate Peter Doherty sees difficult choices ahead.

Australia must resolve a raft of political, ethical and financial dilemmas, he says, to ensure the benefits of biomedicine stay accessible to the greatest number. As the pace of discovery quickens - with new experiments limited only by the human imagination, and companies spending billions bringing new drugs to market - Professor Doherty warns the healthcare system won't cope.

''There's going to have to be a measure of rationing otherwise healthcare budgets are just going to take everything,'' Professor Doherty says.

Peter Doherty receives this Nobel Prize from King Carl XVI Gustaf of Sweden in 1996.

''You will have no money left for education, large-scale infrastructure or anything else, and that's obviously inappropriate.''

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He says the big controversies are around end-of-life issues, with enormous impact for medical costs.

''The great majority of medical dollars are actually being spent in the last year or two of life - often to prolong an existence that is already of very low quality,'' he says. ''And what happens is that so much resource goes to end-of-life that the resource for early life is diminished. So vaccination campaigns may not be properly funded and child health is not as well-supported as it should be.''

Every cent spent on drugs to prolong what may be a very low quality of life in the elderly can't be used to support preventative health education, he says - or to sustain a dynamic research sector or counter the effects of anthropogenic climate change. All of these challenges have huge implications for health and wellbeing.

As the revolution rumbles through biology and medicine, hardly a day goes by without a breakthrough. Scientists are revelling in their relatively new freedom to manipulate genomes in various ways.

''What is being discovered now stands to have a major impact on human society,'' says Professor Doherty, reflecting on the rise of biomedicine during his half-century of research. The University of Melbourne immunologist who won the Nobel prize in 1996 - and recently turned 72 - is himself involved in a National Health and Medical Research Council program to develop a new-generation influenza vaccine.

With the 20th century came tremendous gains in biomedical knowledge, amid rapid development in machines, computing and robotics. The discovery in 1953 of the structure of the basic building block of life, DNA, transformed the science of genetics. The turn of the 21st century marked another major milestone, when the entire human genome sequence was mapped (30,000 genes printed on three tiny chips).

Professor Doherty says coming to know this ''dictionary of life'' has profoundly altered human perception of who we are and our place in the world.

In the near future, he says it's possible we will each have a sort of genetic ''fate map''. Scientists are now striving to identify DNA sequences that confer susceptibility to a range of conditions that afflict us as we age - or genes that predispose us towards early onset of problems such as colon cancer or Alzheimer's disease.

''[But] the revolution looked simpler before we started to know more about it - like everything. It's enormously complex,'' he says. ''For instance, there was a lot of thinking that we would quickly identify specific genetic signatures that would characterise a number of different cancers. We have identified some.''

He points to Gleevec, for instance, a so-called ''miracle pill'' designed to treat some cancers. ''It was one of the drugs made by 'rational drug design', where you look at how specific molecules in a cell can be blocked.'' Developing Gleevec involved expensive synchrotron science and crystallography to identify how atoms and molecules are arranged within a crystal.

''Pharmaceutical companies have to cover the development cost,'' he says. ''They're not exactly modest in what they take back but their expenses are massive.'' Professor Doherty recalls how one Big Pharma took him to lunch via helicopter. Companies also build into their costs the drugs that fail despite millions of dollars already spent. Indeed, we are at the mercy of the international companies for whom a new drug can cost up to $1 billion to bring to market.

This burden is why most drugs are developed in the US. The Australian industry can't wear the cost of carrying a product through to massive clinical trials, though Professor Doherty notes Australia is gaining capacity to do earlier-stage trials that test drug safety and efficacy.

Especially costly are the new class of ''biological'' medicines, or monoclonal antibodies, that make up a third of new drugs designed to treat diseases including cancer, arthritis and asthma. ''Even if they go out of patent, they'll still be expensive because they cost a lot to make.''

Then, he says, if the therapy isn't covered by some insurance scheme, a patient may end up forking out tens of thousands of dollars a year - for life.

''If you can actually treat those tumours and get a cure, that would be great. [But] very likely what you'll be doing is treating and getting a remission - and you may need to continue the drug in the long term.'' Add to that the cost of debility (can the patient still work?) and what if he or she gets an infection - or worse, needs a bone marrow transplant? They may also need a lifetime course of immunosuppressant drugs.

As Professor Doherty puts it: ''You'll gain on the swings and lose on the roundabouts.''

Monoclonal antibodies are also popular candidates in the search for a way to stave off Alzheimer's. ''We don't know whether any of them are going to work, really - it's still early days,'' he says, adding: ''Apart from the massive social benefit, the cost savings for public health systems would, even for very expensive treatments, be massive if we could substantially delay or prevent the onset of this terrible disease.''

Meantime, the prospect of rationing healthcare remains. ''Everyone believes they're entitled to equal healthcare. And no medical professional is going to turn around and say, 'Well, you can't have something because you were a smoker or because you drank a bottle of whisky a day'.''

He believes healthcare systems the world over face greater rationing. But more political power lies with older and wealthier people, he says, so a healthy dose of education about end-of-life issues is crucial.

''The doctors can make a judgment and say, 'OK, if you want to prolong your relative's life at a very low level, that's fine, but you pay for it','' he says.

''The better thing is actually to educate people, so that they would say, 'In case of terminal cancer, I would much rather go into a hospice and have palliative care … We really haven't grappled with this whole issue of Alzheimer's and these dementias where people are totally out of it. Most of us would not want to continue to live under those circumstances,'' he says.

''It really requires a rational discussion which, at least for this issue, seems to be almost impossible in our political system.''

This Living National Treasure wants to ensure healthcare for youth gains the big benefits of the biomedical revolution.

''Society has to protect the future. And the future is with our children and young parents,'' he says. ''You have to have some sort of balance. Increasingly, we don't have the resources to do everything.''